Sunday, 4 May 2008

Blogging Revision

Ok, so I'm not supposed to be blogging because I'm supposed to be revising but I had a wonderful thought - what if I combined the two?

What better way to revise ethics and consent than to discuss it. It's a grey area without a yes or no answer. It is more a matter of common sense and opinion so I'm asking for your opinions on the following scenarios:

1) You are the SHO on an upper GI surgery firm, you are told to explain a diagnosis of gastric cancer and start to consent a schizophrenic patient for surgery.

2) You are a new GP partner in a GP surgery seeing a woman who is going in for a elective operation, and she doesn't want the people in the hospital to know about her Hep C status... it turns out that she thinks if the hospital knows about her Hep C status, her social worker would find out and not let her to see her daughter.

3) A husband slept with prostitute in Thailand on business trip. Wife is unaware but attends GP with sore throat & demands to know what’s wrong with husband & wants same treatment.

So, how might you approach the above situations, go on, leave a comment and help with my revision.


Noel said...

Okay i'll help you out because...well I'm a giver:

1. I'd decline to do the consent. Don't know if an SHO would be operating but I'm sure there's some rule about only doing consent if you're one of the surgeons operating. Besides the psych diagnosis only adds to the problem because you have to decide if the patient is competent to give consent or if you need a proxy. Guess I'd call in Psych to get their take but I'd just as soon not be involved at all.

2. Well it sounds like this lady is misguided. I'd have to explain to her that the social worker won't take her kid away because of that. Then I'd have to encourage her to divulge the info to the hospital staff (although how was it going to stay hidden? I assume it's in her notes somewhere). At the end of the day if she refuses to divulge the info then I'd have to decline to participate in her surgery.

3. First, we have to explain to this lady that I cannot give out medical information on other patients unless she is the legal guardian. The best I can do for her is diagnose her potential STD and then it's up to her to decide where she thinks she got it from. The real issue though is why she thinks it's better to come down to my office to interrogate me about her husband when he's at home in bed with her. I'm sensing some communication issues.

BTW, question 3 is probably why i'm going to specialize. I'm really not interested in being that involved in your family.

fi said...

OK, I'm not a doctor or even a medical student, but, for what it's worth (from the point of view of someone who has studied Medical law and ethics!) here's my opinion:

1) Should the patient's psychiatrist (or other involved health professional) not be involved in explaining the issue to the patient with schizaphrenia on the premise that presumably they have some sort of trusting relationship with him/her? Other than that, I suppose it's a case of seeing whether the schizaphrenic condition is currently under control so as to enable to the patient to understand the gastric cancer and the necessity of the operation. If it is then start the consent gaining process, perhaps also with asking whether s/he would like a family member/carer/friend present. If the condition is not under control then a psychiatrist needs to be called in.

2) Strangely enough, my experience of a pre-op assessment for a hip replacement means that the hospital really wouldn't have a record of something like Hep C unless the patient disclosed it. I probably would explain to her that her Hep C status could not be disclosed to her social worker unless hospital staff had some reason to believe that it would in some way harm her child(?), that disclosing her Hep C status protects her and hospital staff and would ensure better care. And surely not disclosing it and then the hospital staff finding out would probably mean that social workers would be told for fear that the child was at risk as the mother was not taking responsibility for her condition?

3) I assume that the husband is receiving treatment for a STD? If he is then he should have been told to disclose it to his wife, particularly as some STDs remain undetected in women causing more problems long term. Other than that, when the woman comes I would tell her that patient confidentiality means I cannot discuss her husband's health but that I was happy to examine her and prescribe accordingly.

Am I totally off bat?

missbliss said...

I suppose the thing with these ethical dilemmas is that you can't give assurances where it can be held against you ("but the doctor said I'd still have custody of my kids!!") and you can't always pass it off to a senior just because you don't want anything to do with it ("the patient's consultant psychiatrist is on holiday for 2 weeks?!").

Rather you than me!

Marith said...

Right, I'll use this as an exercise, since we don't get all that much ethics around here.

1.) If she's stable, there's no problem. If she's in a psychotic episode, shouldn't consent be acquired from a guardian? I mean, psychiatrist or not, I don't think having somebody explain gastric cancer to a hallucinating patient will do any good.

2.) Explain that the hospital will not divulge that information to the social worker, explain that a child cannot be kept away from her on the basis of hep C, explain that this is important information routinely noted in patients' charts, explain that access to charts is limited to people who are responsible for her treatment and care. I know patients' rights have to be protected, but is this even a possible dilemma? Around here, OR's with infective patients are clearly labeled as such. They put a big HEP B/HEP C/HIV/whatever sign on them. And for good reason, those scalpels are sharp and double gloves are not cut-proof.

3.) I cannot tell you what your husband has or what he is being treated with, because it falls into patient-doctor confidentiality. You, however, have yyy and will be treated with this-and-this medicine.

Nick said...

Hmmm, i'll give my 4th year brain a probing...

1) I'd decline to consent. Get the reg/consultant to do it, and perhaps involve psych - is patient in an acute episode? Is patient able to give consent?

2) Not sure what the current GMC guidance is, but I think along with HIV you have to inform hospital of Hep C status for everyone elses' safety. Inform patient you have to tell them but everyone else will keep it confidential and social worker shouldn't be looking in medical notes anyway so she won't know!

3) Say you can't tell her, simple as

God I hope we don't have ethics situations in our exams, they get me really angry

anna gregory said...

I'm gutted I have only just found your blog. Are you going to carry on writing it when you start as an FY1?


Anonymous said...

Scenario 1: Not withstanding the points above regarding who consents, (and for what it's worth, I too thought it has to be someone who is also performing the surgery (usually a reg or a consultant) I think the Mental Capacity Act probably applies here. Can the patient understand the information, can they retain the information, can they weigh that information up rationally to make a considered decision and can they appropriately communicate that decision? Being delusional or psychotic does not necessarily equal lack of capacity. See the case of Re: C (I think that's the one) where the schizophrenic chap refused consent for amputation of a gangrenous limb. The court sided with him, (and he survived in the end without surgery), despite him being delusional at the time and believing he was an eminent surgeon. So, to answer the question, the first thing to do is to assess capacity, and if you have any concerns about that, it is those concerns which need addressing first before consent.

Scenario 2 Explain and reassure her regarding her concerns, tell her the reasons why it has to be declared, mention that it is already in her notes anyway and discuss patient confidentiality.

Scenario 3 Nothing to add.


Anonymous said...

1. Put it in language the patient understands. Tell him that aliens live in his stomach and that you are going to use the beamer to get them out, is that ok...

Dragonfly said...

Aliens live in his stomach. Hilarious. I bet lots of people have wanted to say things like this. Heck, I was tempted just the other week to present a patient with a tin foil hat to stop the hospital stealing his thoughts, but he probably wouldn't have taken it because he thinks I work for Mossad.

Lily said...

A friend at uni made a really harsh but amusing comment the other day. He said how much, after a day of struggling to clerk psych patients, he's tempted to agree with delusional patients and say things like "Yes... I can hear them too! You're right..." and then just completely deny it later to confuse them even more.

So so so harsh. So so so wrong. But amusing none the less.

For anyone who doesn't see the funny side to that I'd like to point out noone I know would actually do that! Deep down we're caring and sensitive souls.

j00ni said...

So did you read the comments for scenario 1 then TLM?? And if so I hope you'll be thanking the respondents come results day ;)